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Henry Ford Medical Group: The
Chronic Care Excellence Initiative
The result of this collaborative work
would be a shared care plan—an indi-
vidualized clinical summary and action
plan for self-management that
outlines specific steps to achieve
agreed-upon health goals and clinical
targets. This project developed and
tested an integrated approach to
chronic care support that resulted in
improved clinical and functional
outcomes for patients with heart fail-
ure, diabetes, coronary artery disease,
and other conditions.
INNOVATION AND COMMUNITY COLLABORATION
TRANSFORMS HEALTHCARE DELIVERY,
IMPROVES PATIENT OUTCOMES, AND MEETS
MARKET DEMANDS.
Henry Ford Medical Group
(HFMG) is a nonprofit, integrated
care system that includes a hospital,
Representatives from Henry Ford Medical Group are named honorees of the 2006 AMGA Acclaim (left to right):
William Conway, M.D., Senior Vice President and Chief Quality Officer, Henry Ford Health System (HFHS);
admitting more than 22,000 patients
Roberta Eis, R.N., M.B.A., Program Manager, Office of Clinical Quality and Safety, and Bruce Muma, M.D., each year, and 25 clinics with more
Medical Director, Chronic Care Services and Northern Region, Henry Ford Medical Group. than 1.8 million physician visits a
year. There are more than 7,500
Editor’s Note: The American Medical completely new approach to chronic employees, including 590 physicians
Group Foundation, the philanthropic arm of disease management. The decision and 270 clinical professionals provid-
the American Medical Group Association, was made to move away from the ing care in 45 medical specialties and
annually presents the Acclaim Award to traditional visit-centric focus on symp- subspecialties in Detroit and
organizations that embrace the Institute of toms and problems to the proactive surrounding suburbs.
Medicine’s aims for an ideal healthcare development of the individuals’ role in
system and have demonstrated dramatic, managing their healthcare needs. The The IOM Aims
measurable progress in moving their organi- project’s initial framework, based on HFMG is developing a new
zations toward one or more of the aims. the IOM aims and rules and the model of care for chronic disease to
Henry Ford Medical Group was named a Wagner Chronic Disease Model, address the gap between clinical
2006 Acclaim Award Honoree for the assumed that improved clinical and targets and measured outcomes.
initiative described in this article. functional outcomes would result from Clinical outcomes have not kept pace
collaborative work between informed/ with impressive advances in medical
I
n early 2005, Henry Ford Medical empowered individuals and proactive knowledge, therapies, and technol-
Group (HFMG) launched a devel- care teams prepared to provide educa- ogy. Only about half of the treat-
opment project to create a tion, care coordination, and coaching. ments known to improve health are
14 GROUP PRACTICE JOURNAL JULY/AUGUST 2007
I Assessment of progress towards
currently being delivered. The goal projected to increase by more than 1
clinical and personal health goals
of this new approach to care is to percent per year.1 Chronic diseases
by monitoring outcomes using
support individuals with chronic account for 70 percent of all deaths
population registries and rules to
disease in developing the skills and alert teams to gaps in the United States and more than
resources they need to effectively 60 percent of our nation’s medical
manage their health—to achieve The primary goal of this project care costs. Despite the prevalence
their best possible health outcomes. was to develop and test an inte- and impact of these chronic diseases,
In early 2005, as part of strategic grated approach to chronic care we still rely on an acute care model
planning, a development project was support that results in improved that does not adequately support
launched with the charge to develop a clinical and functional outcomes. individuals with chronic diseases.
completely new approach to chronic This required the development, HFMG’s visits mirror the national
disease management. The decision testing, and implementation of statistics cited above. In 2004 and
was made to move away from the tools that enable collaboration and 2005, 74,400 unique patients were
traditional visit-centric focus on coordination among patients, coded with diabetes (21,200), coro-
symptoms and problems to the proac- providers, specialty care, and nary artery disease (9,000), conges-
tive development of the individuals’ support services and resources. tive heart failure (4,500), asthma
role in managing their health care To simultaneously bring the (17,600), and hypertension (39,000).
needs. The vast majority of health benefits of evidence-based advances Many patients had more than one of
choices are made during the 99.6 in chronic disease management these common chronic illnesses.
percent of time when people are not while developing and testing new Adults in the U.S. receive about
face-to-face with a clinician. The approaches, different teams were half of needed medical care for the
initial framework, based on the IOM formed, each with specific goals and leading causes of death and disability.2
aims and rules and the Wagner deliverables. One team was charged The gap of patients with chronic
Chronic Disease Model, assumed that with improving care for patients with diseases at HFMG meeting targets
improved clinical and functional heart failure. This involved imple- mirrors national statistics. Data for
outcomes would result from collabo- menting evidence-based processes the first quarter of 2005 showed that
rative work between and clinical solutions across the 41.9 percent of patients with diabetes
informed/empowered individuals and continuum of care while reducing had an A1C less than 7 and were up-
proactive care teams prepared to unnecessary hospitalizations and to-date; 44.9 percent had an LDL
provide education, care coordination, associated costs. Another team less than 100 and were up-to-date.
and coaching. The result of this focused on testing patient-centered
collaborative work would be a shared approaches for diabetes management To escape the “tyranny of the visit”
care plan—an individualized clinical in primary care. A third team The “tyranny of the visit” refers to
summary and action plan for self- focused on workflow redesign and the current situation in which
management that outlines specific IT requirements that would be patients receive the majority of
steps to achieve agreed-upon health needed to sustain and truly change health care delivered by physicians in
goals and clinical targets. care throughout the entire organiza- face-to-face visits. The tyranny of
This new team-based approach to tion. A chronic disease steering the visit was created by the current
chronic disease management would committee was created with both payment structure, and represents a
support individuals and care clinical and business line leaders to core barrier to adequately support
providers through: monitor progress and address barri- individuals in the development of
ers during the change process. self-management skills necessary to
I Team-oriented shared care The tables on pages 16 and 20 reduce death and disability associ-
planning summarize how the IOM aims were ated with chronic disease.
I Support of plans with automated used to guide the overall project’s Behavior patterns represent the
prompts and follow-up goals and objectives and how results single most prominent domain of
support each of the IOM rules. influence over health prospects in the
I Education, information, and United States3 and account for 40
coaching Why Goals Were Selected percent of preventable deaths in the
I Intentional coordination between To address the quality gap United States.4 Self-management of
patients, clinicians, support Approximately 133 million behavior patterns for patients with
services, and specialty care people in the United States live with chronic disease drives reducing
(prepared patients and staff) a chronic condition. That number is preventable death and disability from
JULY/AUGUST 2007 GROUP PRACTICE JOURNAL 15
IOM Aim Project Goals and Objectives ment responsibilities were linked with
I Coordinate care throughout the system through use of case managers, operations leaders to develop, test,
Safe
standardized processes for planned care, and automated alerts, and launch changes that contribute to
reminders, and follow-up the vision of a new model of care for
Effective I Support people as they care for themselves on a daily basis, when and patients with chronic disease.
where they need it, with self-care tools, information, encouragement from
coaches, and collaboration from providers Organizational Transformation
Patient-Centered I Collect information related to patient preferences and needs to allow the Recognizing patients as care
care team to anticipate and respond to their unique needs managers, who make the most impor-
I Collaborate with patients to develop and document shared care plans tant daily decisions related to their
that outline specific steps to achieve agreed-upon health goals and health, required major changes in how
clinical targets care resources were organized and
Timely I Decrease patient wait time by having lab testing and education available made available. Roles and responsibili-
at the point of care and on demand when patients need support to ties among specialty providers,
manage their health
primary care, and case managers were
Efficient I Facilitate, coordinate, and improve access to resources that go unused as reorganized to focus on giving the
patients and providers struggle to find the right support at the right time
patient access to support outside of
Equitable I Customize each interaction so that all patients can receive the care and scheduled visits. This required looking
services needed
beyond traditional department-
chronic disease and includes ongoing reflect their goals and values. To help focused economics and structures to
choices related to diet, exercise, patients manage their own care more redesign care processes and roles that
medication adherence, and smoking effectively, HFMG needed to gain a truly are centered on patient needs and
cessation. Individuals with chronic better understanding of their needs preferences.
disease make these behavioral choices for follow-up and support and how
8,760 hours per year, yet the typical to communicate their preferences Leadership Commitment
patient with a chronic illness spends and values to the care team. The goals and objectives of the
approximately 2 hours per year—or project are central to the organization’s
.04 percent of the total year—with a Global Action Steps stated mission and are specifically
physician in a face-to-face visit. The plan for a new approach to referenced in its 2006 strategic plan.
chronic disease management The organization started a planning
To understand and meet the needs of assumed that support for individuals process in early 2005 that focused on
patients with chronic diseases would be creating alignment with all the people
HFMG’s quality improvement strengthened within the existing in the organization to focus on a
efforts successfully implemented organization of care delivery rather desired change. The struggle to
disease-specific guidelines and proto- than by building a separate and respond to numerous change initia-
cols that improved clinical outcomes potentially competing support struc- tives along with daily operational
in a number of important areas. ture to carry out the following steps: needs can result in a slow and frustrat-
Progress towards personalized care, ing process. Staff involvement in the
however, lagged behind other efforts. 1. Assess patients’ values and strategic plan ensures buy-in through-
Disease-specific guidelines and preferences out all levels of the organization and
specialty centers that focus on expert 2. Identify and stratify risk spreads the work of change over as
consultation and treatment plans many people as possible. That work
related to a single condition are not 3. Negotiate a shared care plan includes careful listening to patients
equipped to address the day-to-day 4. Arrange for self-care support tools for their needs, sensing changes in the
care coordination and personal issues and resources environment, defining an agenda of
patients face when dealing with needed change, and developing effec-
chronic disease. Patients rarely have a 5. Provide follow-up and tive plans to accomplish the change.
single condition, and struggle to keep reinforcement The resulting strategic plan was
up with a series of plans that may not This required major changes in approved by both a community and
reflect their lifestyle or preferences. roles and responsibilities at the care clinical board of directors and distrib-
People are simply more engaged in team level, along with significant uted to all staff. The strategic plan was
plans that they helped create and investment in IT infrastructure. The then linked to the work of each indi-
understand. And these plans need to teams charged with these develop- vidual staff member in planning
16 GROUP PRACTICE JOURNAL JULY/AUGUST 2007
sessions held at the department level. management system would improve an all-day meeting to formalize how
care and reduce costs for patients to best support individuals with
Accountability with heart failure, it was decided to heart failure. The work of the group
The senior leadership team— bypass some of the typical testing included criteria for participation in
including the CEO, CFO, CMO, and training that usually precedes a the heart failure clinic, how to best
and CIO—was well represented on system-wide change. Instead, after a use case managers, and how to
the steering committee of this project thorough review of the literature and incorporate the heart failure case
and received monthly reports on the vendors to supply this service, leaders management program to support
progress of the teams charged with agreed to support a system-wide individuals. The participants in this
this innovation project. They were enrollment of patients most likely to rapid design session defined the
involved in all steps of the planning benefit, using clinical rules that following:
process, including a weeklong initial allowed nurse case managers to
series of all-day design meetings held directly connect with patients with- I “Triggers” to identify patients with
in February 2005. The physician out obtaining prior physician heart failure, including hospital
leaders of primary care and informa- approval. Training and communica- admissions
tion technology and strategic devel- tions to all involved sites were deliv- I Process and criteria to stratify risk
opment were given ownership of the ered simultaneously with patient initially and ongoing for all
project. The quality improvement recruitment and launch of the new patients with heart failure and
staffs were given project manage- service. This resulted in improving determine which patients are best
ment responsibilities. care for hundreds of patients in less treated within the heart failure
The organization uses a systems- than 90 days. clinic and which patients are best
and production-oriented approach to Another difficult decision was to treated within primary care
improvement in addition to tradi- focus added resources in primary
I Protocols to improve care for
tional quality improvement method- care, where reimbursement for patients diagnosed with heart
ologies. This approach emphasizes point-of-care services would be less failure
creating customer value using rapid likely but the services more available
process improvement techniques and to patients. This approach would I Roles to coordinate discharges
workflow redesign to speed progress also be disruptive to the workflow of from the hospital and enrollment
towards the IOM aims. Management several other departments, such as in the program
is dedicated to leading change and laboratory and diabetes education, I Protocols to enable case managers
standardizing work to sustain and change relationships between to make simple changes in diuret-
improvements. Improvements are members of the care team. ics, order labs, etc.
continually being tested and imple- The scope of the project also
I Protocols to improve quality
mented throughout HFMG. This clearly would require a significant
measures for patients with heart
project was given high priority for investment in IT infrastructure and
failure
staff experienced in implementing development that would span across
successful projects. at least two to three years. This type Later in May, a vendor was
Accountability is enhanced by of investment required involvement selected to design a telephone
using highly visible reporting meth- and approval at the board level. It support system for patients with
ods, including dashboards that are was approved in April 2006. heart failure. Enrolled patients call a
posted in clinical and administrative phone number daily and report their
areas where the data is discussed as Implementation morning weight and other symp-
part of weekly planning huddles. Heart Failure toms by answering five questions
Clinical and process measures are In April 2005, the clinical board using their phone’s touch-tone
also sent to leaders as part of admin- endorsed a plan to focus on improv- keypad. Their responses trigger a
istrative reviews. ing the care of patients with heart work list of patients that case
failure. managers contact (usually about 10
Tough Decisions On May 6, 2005 clinical leaders percent of the patients) and manage
The most difficult decisions faced and staff representing the care team using the protocols that the expert
in this project have been around how across the care continuum—from team approved.
fast and where to spread change. cardiology, primary care, the heart The organization anticipated 1
Because of the strength of evidence failure clinic, the hospital, and case manager for every 350 patients;
that an integrated telephonic disease education services—participated in 4 case managers were added to
18 GROUP PRACTICE JOURNAL JULY/AUGUST 2007
primary care teams in May 2005 to FIGURE 1
initially focus on heart failure. Case Averted Hospitalizations Among Heart Failure Patients
managers used the EMR to docu-
ment and to communicate with Month All Cause Baseline Expected Actual Averted
Admissions Enrolled Admission Admissions Admissions Admissions
other care team members.
Rate
In May 2005, patients who were
Dec-05 229 327 1.4 38 13 25
part of the heart failure clinic were
Jan-06 195 390 1.4 45 11 34
the first to be enrolled in the daily
Feb-06 189 455 1.4 53 19 34
management program. The staff of
the heart failure clinic was involved Mar-06 204 545 1.4 63 23 40
in the rapid design sessions for this
program, so no additional staff FIGURE 2
education was needed in this area. Diabetes Outcomes Improvement
In June 2005, the case managers
90
started enrolling patients who were
hospitalized with a diagnosis of heart 80
failure in the program.
70
Provider and staff education on
the goals and implementation plan 60
took place at each individual primary
care clinical site (19 sites) starting in % Performance 50
June 2005. Clinical leadership repre-
40
sentatives provided lunch and gave a
PowerPoint presentation at each site. 30
Case managers were also present to
20
answer questions and to start review-
ing patient lists with providers. 10 A1C < 7
In July 2005, HFMG started to A1C < 9
enroll primary care patients who 0
Apr-05
LDL < 100
Feb-06
Month UMAR UTD
carried a diagnosis of heart failure
into the program through a letter
campaign directed to patients.
diabetes educators; on-demand visits
process was developed to contact
at point of service; and visit planning.
Diabetes These key elements were imple- patients due for services and
A chronic disease innovation pilot mented beginning in July 2005. patients with clinical outcomes out
was started in family medicine and of target. Additional methods were
internal medicine with an initial Point-of-Care Testing designed to record information and
focus on diabetes in June 2005. This A process was developed for all number of contacts, as well as to
area had a large population needing care teams to provide labs at the obtain appropriate labs. Patients
intervention and involved well- time of the visit. These tests were receptive and responsive to
defined measurements. included A1C, Cholf and albu- the new process, and care needed
The diabetes population in the min/creatinine ratio. This concept was reinforced.
organization totals between 13,000 supports treating to target, as it
and 15,000 patients: 10,000 patients reduces time lost between visits. Certified Diabetes Educators
age 18 to 75 (includes 2500 adult Advances in therapy are quicker Certified diabetes educators
endo patients); approximately 255 and the education process is were available on demand during
pediatric endo patients; and 2,092 improved, resulting in an overall patient visits. This allowed the
patients over 75. improvement in efficiency. opportunity to address self-
Team members included physi- management needs, recommended
cians, quality improvement staff, Population Management labs, and therapy recommenda-
nurses, and diabetes educators. Key The process implemented tions, based on patient assessment.
elements included: point-of-care test- involves a proactive, systematic Follow-up recommendations were
ing; population management; certified process to bring patients in. A also addressed and facilitated. This
JULY/AUGUST 2007 GROUP PRACTICE JOURNAL 19
IOM Recommended Rule Project Results
Care based on continuous I Daily management of 574 patients with heart failure using an automated telephonic system and 4 case
healing relationships managers.
I Case managers and educators were added to the care team to have direct communication with providers and
patients.
I Non-physician roles (chronic disease specialist and population manager) were created to support individu-
als with coaching, education, and care coordination for more effective disease management in primary care.
Customization based on I Principles of motivational interviewing were embedded into tools designed to help patients develop self-
patient needs and values management goals and meet medical treatment targets.
I Staff were trained in motivational interviewing strategies to collaboratively set goals.
I Patients were included in all levels of process and system redesign.
I Heart failure patients were given modified equipment for daily weights and contacting case manager based
on individual needs.
The patient as the source I Patients were invited to enroll and use services depending on their preferences.
of control I Patients were given self-care support tools and resources based on their preferences and needs.
I Patients learned to collect specific data to monitor heart failure (i.e., daily weights) and diabetes (i.e., blood
glucose) and were instructed on how to use the data to make adjustments in medication by consulting with
an assigned case manager or certified diabetes educator.
Shared knowledge and I All patient information was added to a single system-wide EMR, making any change in medication or status
the free flow of information available to the entire care team, including the patient.
I Patients were given care plans with medications, follow-up recommendations, and support resources.
I Patients were encouraged to use a patient portal that allowed them to view recent lab data.
Evidence-based decision I Treatment recommendations were based on evidence-based guidelines and were added to medical educa-
making tion training and decision-support tools.
I Evidence-based guidelines and alerts were embedded in standing orders and protocols.
Safety as a system priority I Population management oversight was implemented using automated prompts and follow-up actions.
I An automated telephone system was implemented to collect data and monitor risk status of patients with
heart failure, with a primary case manager assigned to coordinate care.
I All patient information was added to a single system-wide EMR, making any change in medication or status
available to the entire care team.
The need for transparency I The organization tracked and publicly reported 71 measures related to 24 conditions.
I Progress towards clinical goals was assessed by monitoring outcomes via automated reports for each
physician; results were made available to the entire care team and were used to notify patients.
Anticipation of needs I Components of planned care were added to a standardized rooming and visit-planning process.
I Patients participated in planning and evaluating quality improvement initiatives.
I Methods were developed and used for contacting patients due for services and patients with outcomes not
meeting goals and for obtaining appropriate labs.
Continuous decrease I Unnecessary hospital admissions were reduced for heart failure patients.
in waste I Lead time for initiating and adjusting diabetes medications was reduced by having point of care diabetes
testing and on-demand CDE availability.
Cooperation among I Teams working on process and system redesign represented clinicians from primary and specialty care and
clinicians all other members of the care team.
process provided an opportunity to Planned Care Visits providers, and other caregivers—
identify needed resources for Planned visits focus on developing should result in evidence-based care
patients, integrate diabetes self- and monitoring plans for improved being delivered more often, with
management tools, set goals, and health, rather than on acute care improved outcomes for patients. The
work collaboratively with the needs. The concept of developing a pilot proved that visit planning is key
providers. customized plan for each patient—to during the visit, as well as pre- and
be shared among the patient, post-visit, and that operations support
20 GROUP PRACTICE JOURNAL JULY/AUGUST 2007
and follow-through are necessary. promote prevention and the develop- cian support of patient enrollment.
ment of healthy lifestyle habits. Challenges encountered in the
Chronic Disease Model Development diabetes innovation pilot included
A workgroup that has patient, Biggest Challenges lack of resources to support primary
quality-improvement, clinical, and Collaborative decision-making care providers and patients, incon-
education staff representation was and care-planning require both a sistent or no process to manage
formed to develop and test self- change in physician and patient follow-up activities, change in
management support tools and cultures and an acceptance of existing laboratory processes, care
processes at two sites starting in different roles and priorities within team engagement with change,
October 2005. This group received a the healthcare community. Health perceived lack of time for existing
grant to participate in a nationally literacy and economic barriers also staff, and process for pre-visit plan-
sponsored learning collaborative on slow the full implementation of a ning that included comprehensive
self-management support in primary chronic care support model to those assessment of diabetes needs.
care at the same time. A guidance at lower risk, where the return on
team of senior leadership with investment is less clear to a health- Results
research and finance experts was care provider system. Heart Failure
convened in late 2005 to monitor the Another limitation of this project is HFMG measured success rates by
progress of the team. Plan-Do- that it requires significant data collec- looking at averted hospitalizations in
Study-Act (PDSA) improvement tion and integration to create reports the group of heart failure patients
processes and data collection are that are timely and useful at the point that were part of the heart failure
reported monthly to the grantee as of care. Just as providers have become case management program. They
well as project leaders and sponsors. accustomed to having graphs of labo- estimated the impact of program
In November 2005, a care-plan- ratory data at their fingertips to guide strategies by looking at the admission
ning visit was tested with 20 volun- treatment decisions, other measures rates of the population intervened
teer patients in a primary care site. that guide shared decision making upon compared to the population as
Each patient received a care plan and need to be displayed in a way that is a whole (see Figure 1).
follow-up based on goals collabora- easy to interpret and monitor. While HFMG has plans to expand this
tively developed in a visit with a the need for training both clinicians initiative into other areas. The first
nurse and physician. Shared care and patients is obvious, this new set of expansion will be case management
planning uses principles from moti- measures related to preferences and for patients not enrolled in the phone
vational interviewing to support patient needs requires a major invest- program. They are looking at expand-
individuals in articulating values, ment in technology infrastructure and ing into other chronic diseases with
resolving ambivalence about values, ongoing management. this tool, including those with diabetes
and planning small steps to build The biggest challenge posed and COPD. The phone program will
confidence. A psychologist, certified with the development and imple- be part of an expanded chronic disease
as a trainer in motivational inter- mentation of the heart failure case self-management support services for
viewing, conducted trainings for management program was physi- patients as part of the new approach to
involved staff and participated in cian and patient buy-in. Patients chronic disease management.
several provider conferences to were resistant to having to call in
increase awareness of this approach daily to report weight and signs and Diabetes
to goal-setting. symptoms. HFMG had about a 50 The diabetes innovation pilot
In March 2006, this group and percent decline rate from patients provided many key learnings. The new
leaders of the other projects described when they were approached about methods and processes provided more
presented results to more than 400 joining the program. Providers were opportunity to engage patients at the
leaders throughout the organization. grateful for any help they could get point of service. Interactions with a
In April, 40 leaders, along with with their patients, but not all proactive care team served to reinforce
patient representatives, gathered for thought that a daily phone manage- goals, and patient preferences could be
the first of 3 daylong meetings to ment program would be beneficial easily addressed. The need for certain
review findings and to define an ideal to all of their patients with heart support services became evident—
process for self-management support failure. An expert group was asked social services, mental health, coach-
that could be made available to all to better define the types of heart ing, and insurance support.
patients with chronic disease—and failure most likely to benefit from Measurable findings include:
ultimately for healthy patients—to daily monitoring to improve physi-
22 GROUP PRACTICE JOURNAL JULY/AUGUST 2007
Decreased lead time solely on disease-specific measures. ments. This information and progress
I Labs: From 5 days (6925 minutes) Several redesign sessions were sched- towards goals needs to be easy to find
to 48 minutes (from patient walk- uled to continue through 2006, with and to track over time.
ing in the door to receiving a significant focus on development of
results) IT enhancements to efficiently view References
and create care plans that patients 1. Partnership for Solutions: Johns Hopkins
I Access to certified diabetes educa- University, Baltimore, MD for the Robert
tor (CDE): 1 day to 4 weeks; 15 to can use to guide daily decisions Wood Johnson Foundation. September
regarding care. 2004 Update.Chronic Conditions: Making
30 minutes; “teaching moment” the Case for Ongoing Care.
opportunity with patient in clinic 2. E.A. McGlynn, S.M. Asch, J. Adams, J.
Advice Keesey, J. Hicks, A. DeCristofaro, and
Patient satisfaction E.A. Kerr. 2003. The Quality of Health
Adding support services and Care Delivered to Adults in the United
I 82 percent said point-of-care labs
resources requires a continual focus States. New England Journal of Medicine.
were helpful 348(26): 2635-2645.
on reducing waste in existing
3. J.M. McGinnis, P. Williams-Russo, and
I 100 percent said CDE was helpful processes and development of auto- J.R. Knickman. 2002. The Case for More
mated decision support. Although the Active Policy Attention to Health
Satisfaction was high among Promotion. Health Affairs, 21(2): 78-93.
patients, providers, and care teams. majority of components needed to 4. J.M. McGinnis and W.H. Foege. 1993.
Improvement in outcomes is docu- create and share an effective care plan Actual Causes of Death in the United
States. JAMA. 270(18): 2207-2212.
mented in Figure 2. are currently available in HFMG’s
electronic medical record, it is impos- Adapted from the 2006 Acclaim Award
Chronic Disease Model Development sible to efficiently create a single, Application of Henry Ford Medical
Success in this area is measured easy-to-use report for either patients Group, submitted by Bruce Muma,
by the pilot results to date and strong or the care team. Finding goals and M.D., Medical Director, Chronic Care
organizational support for workflow personal preferences requires exten- Services and Northern Region.
redesign to support all patients with sive and time-consuming review of
chronic disease, instead of focusing past transcriptions or scanned docu-
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